Form Hca 15 – Fill Out and Use This PDF

The HCA 15 form is essential for healthcare providers who need to request adjustments to paid claims. It is used for various adjustments including changes to third-party liability amounts, Medicare adjustments, and refund requests. To ensure a smooth adjustment process, completion of this form along with required documents like the Remittance Advice and corrected claim or Evidence of Medicare Benefits (EOMB) is necessary.

For providers looking to make adjustments to claims, accurate completion of this form is crucial. Click the button below to start filling out your HCA 15 form now.

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Form Hca 15 PDF Details

Managing healthcare claims can be a complex process, involving meticulous details that, if mishandled, could lead to financial discrepancies. In Oklahoma, healthcare providers navigating this terrain have a critical tool at their disposal: the HCA 15 form. This form serves multiple purposes, including the adjustment of paid claims for services ranging from standard medical care tracked by the CMS-1500 to dental services and crossover Part B claims. Its design caters to a variety of adjustment needs, such as changes to third-party liability amounts, refund requests, or corrections to Medicare adjustments, each necessitating detailed documentation such as the Explanation of Medicare Benefits (EOMB) or insurance EOMBs. Providers must meticulously fill out sections detailing provider information, the reason for adjustment, claim and client identification, and the specifics of both current and desired claim data. To facilitate the adjustment process, the form also requires accompanying remittance advice and a corrected claim, if applicable. This effectively makes the HCA 15 form an essential part of the Oklahoma Health Care Authority's procedural framework, ensuring that claim adjustments are processed efficiently and accurately for both providers and recipients.

Question	Answer
Form Name	Form Hca 15
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	hca 15 oklahoma healthcare authority form

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	CMS-1500, DENTAL, CROSSOVER PART B PAID CLAIM ADJUSTMENT REQUEST
	Mail completed requests to: OHCA - Adjustments, 4345 N. Lincoln Blvd., Oklahoma City, OK 73105
	Mail Refunds to: OHCA- Finance, P.O. Box 18299, Oklahoma City, OK 73154-0299

1) PROVIDER NUMBER:		(2) REASON FOR
		ADJUSTMENT: (Check appropriate
		Box)
PROVIDER NAME/ADDRESS:		Box)
PROVIDER NAME/ADDRESS:		a Change TPL Amt. (Attach all EOMB’s that apply)
		a Offset or Refund of entire claim amount
		(check block 10 )
PHONE NUMBER:		a Change information as indicated in blocks 13-16

CONTACT PERSON:		a Medicare Adjustment ( Attach all EOMBs that apply to
		this adjustment )

(3) CLAIM NUMBER ( ICN )	(4)CLIENT ID NO.		(5) DATE OF SERVICE
			From:	Thru:

(6) CLIENT NAME		(7) AMOUNT PAID	(8) REMITTANCE ADVICE DATE

(9) GIVE COMPLETE EXPLANATION OF		ADJUSTMENT OR REFUND REQUEST:

(10)TYPE OF ADJUSTMENT a Underpayment Adjustment

Overpayment Adjustment (Deduct from from future payments) a Refund Adjustment (Check attached)

Check number:

(11) CLAIM TYPE		(12) MEDICAID PROGRAM
a	Dental	Fee for Service
a	Crossover	SoonerCare
	CMS-1500

LIST THE INFORMATION TO BE CORRECTED IN THE BLOCKS BELOW. IF NO LINE NO. IS ASSOCIATED WITH THE CORRECTION, ENTER A ZERO (0) IN THE LINE NUMBER FIELD. (i.e. TPL APPLIED WOULD ALWAYS BE LINE # 0.)

(13) LINE NO.

(14)DESCRIPTION OF INFORMATION TO BE

CORRECTED

(15)

CURRENT

INFORMATION

(16)

CORRECTED

INFORMATION

17) SIGNATURE: _________________________________________________ (18) DATE: _____________________

OHCA Revised 09/03/2014

HCA-15 (p1)

STATE OF OKLAHOMA

OKLAHOMA HEALTH CARE AUTHORITY

CMS-1500, DENTAL, CROSSOVER PART B PAID CLAIM ADJUSTMENT REQUEST

INSTRUCTIONS

A completed adjustment request form is required for each claim you are requesting to be adjusted. In addition, a copy of the Remittance Advice and a copy of the corrected claim will also facilitate the adjustment process. If the adjustment request is for a Crossover claim attach a copy of the Medicare EOMB or if the request is for an adjustment to the TPL amount attach a copy of the insurance EOMB.

1PROVIDER NUMBER

PROVIDER NAME/ ADDRESS PHONE NUMBER

CONTACT NAME

2REASON FOR ADJUSTMENT

3CLAIM NUMBER

(ICN)

4CLIENT ID NO.

5DATES OF SERVICE

6CLIENT NAME

7AMOUNT PAID

8REMITTANCE ADVICE DATE

9EXPLANATION

10TYPE OF ADJUSTMENT

11CLAIM TYPE

12PROGRAM

13LINE NO.

14DESCRIPTION

15CURRENT INFO

16CORRECTED INFO

17SIGNATURE

18DATE

Enter your 9 digit billing provider number and 1 character service location

Enter your current billing name and address

Enter phone number of contact person

Enter a contact name

Check the appropriate box for the reason you are requesting an adjustment

Enter the Internal Control Number of the claim you wish to adjust. This can be found onthe Remittance Advice. (Use the most current ICN for the claim to be adjusted.)

Enter the recipient’s 9 digit identification number

Enter the From and Thru Dates of Service as billed on the claim

Enter the First and Last Name of the Recipient

Enter the Paid Amount of the claim to be adjusted

Enter the date of your Remittance Advice on which the claim last paid

Give a clear explanation for the requested adjustment or refund

Check the appropriate box for the type of adjustment you are requesting:

*Underpayment – An adjustment to a claim in which you are requesting additional payment, or for which you are requesting a change to the claim’s data which will result in no net change in payment.

*Overpayment – An adjustment to a claim for which you are requesting that an overpaid amount be deducted from your future payments. (This may be a recoupment of a portion of the claim or the entire amount of the claim.)

*Refund – Same as overpayment except that you are submitting a refund check for the overpaid amount. (A refund may be applied to a portion of the claim or to the entire amount of the claim.)

Check the appropriate box of the claim type to be adjusted.

Check the appropriate box of the program to which the claim to be adjusted is associated.

Enter the number of the line that data is to be adjusted. If the adjusted data is not associated to a specific line on the claim, enter a zero (0) in this field

Enter a brief description of the data that is to be corrected on the claim

Enter the information as stated on the current claim that is to be adjusted

Enter the corrected information for the claim

Enter signature of appropriate person (physician, billing clerk, etc. – not required)

Enter the date you are submitting this request (Required)

OHCA Revised 09/03/2014

HCA-15 (p2)

How to Edit Form Hca 15 Online for Free

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With regards to the fields of this particular document, this is what you should do:

1. You will need to fill out the Form Hca 15 correctly, so be mindful while filling out the parts containing all these blank fields:

2. Once your current task is complete, take the next step – fill out all of these fields - TYPE OF ADJUSTMENT a Underpayment, CLAIM TYPE a Dental a Crossover, CMS, MEDICAID PROGRAM, Fee for Service SoonerCare, LIST THE INFORMATION TO BE, LINE NO, DESCRIPTION OF INFORMATION TO BE, CORRECTED, CURRENT, INFORMATION, CORRECTED INFORMATION, SIGNATURE DATE, OHCA Revised, and HCA p with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

Be very attentive when filling out CMS and CLAIM TYPE a Dental a Crossover, because this is where a lot of people make mistakes.

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Form Hca 15 – Fill Out and Use This PDF

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